Weinstein 2010

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The American Journal of Drug and Alcohol Abuse, 36:277–283, 2010
Copyright © Informa Healthcare USA, Inc.
ISSN: 0095-2990 print / 1097-9891 online
DOI: 10.3109/00952990.2010.491880

Internet Addiction or Excessive Internet Use
Aviv Weinstein, Ph.D.
Hadassah Medical Organization, Nuclear Medicine, Ein Kerem, Jerusalem, Israel

Michel Lejoyeux, Ph.D.
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Hospital Bichat Claude Bernard, AP-HP, Psychiatry, Paris, France

Background: Problematic Internet addiction or excessive Internet use is characterized by excessive or poorly controlled preoccupations, urges, or behaviors regarding computer use and Internet
access that lead to impairment or distress. Currently, there is no
recognition of internet addiction within the spectrum of addictive
disorders and, therefore, no corresponding diagnosis. It has, however, been proposed for inclusion in the next version of the Diagnostic and Statistical Manual of Mental Disorder (DSM). Objective:
To review the literature on Internet addiction over the topics of
diagnosis, phenomenology, epidemiology, and treatment. Methods:
Review of published literature between 2000–2009 in Medline and
PubMed using the term “internet addiction. Results: Surveys in the
United States and Europe have indicated prevalence rate between
1.5% and 8.2%, although the diagnostic criteria and assessment
questionnaires used for diagnosis vary between countries. Crosssectional studies on samples of patients report high comorbidity
of Internet addiction with psychiatric disorders, especially affective disorders (including depression), anxiety disorders (generalized anxiety disorder, social anxiety disorder), and attention deficit
hyperactivity disorder (ADHD). Several factors are predictive of
problematic Internet use, including personality traits, parenting
and familial factors, alcohol use, and social anxiety. Conclusions
and Scientific Significance: Although Internet-addicted individuals have difficulty suppressing their excessive online behaviors in
real life, little is known about the patho-physiological and cognitive
mechanisms responsible for Internet addiction. Due to the lack of
methodologically adequate research, it is currently impossible to
recommend any evidence-based treatment of Internet addiction.
Keywords Behavioral addiction, excessive Internet use, Internet

Problem Definition
Problematic Internet use, or addiction, is characterized by
excessive or poorly controlled preoccupations, urges or behaviors regarding Internet use that lead to impairment or distress.
Address correspondence to Dr. Aviv Malkiel Weinstein, Ph.D.,
Hadassah Medical Organization, Nuclear Medicine, Ein Kerem,
Jerusalem, 91120, Israel; E-mail: [email protected]

The condition has attracted increasing attention in the popular
media and among researchers, and this attention has paralleled
the growth in computer use and Internet access (1). Phenomenologically, there appear to be at least three subtypes: excessive
gaming, sexual preoccupations (cybersex), and e-mail/text messaging. Addicts may use the Internet for extended periods, isolating themselves from other forms of social contact, and focus
almost entirely on the Internet rather than broader life events.
In a sample of Italian adolescents, 36.7% showed signs of problematic Internet use. They used the Internet for many hours
per week, mostly utilized dysfunctional coping strategies and
showed worse interpersonal relations than peers who do not
show signs of problematic Internet use (2). Others have suggested that Internet addiction can be explained by a need to
escape from oneself and that may account for the excessive
playing of Internet games (3).
There is considerable controversy with respect to diagnosis of Internet addiction and whether it ought to be included
as a diagnosis entity in the Diagnostic and Statistical Manual
of Mental Disorders, Fifth Edition (DSM V). Several impulse
control disorders have been suggested to have similarities to
substance addictions. These include pathological gambling and
kleptomania. Computer/video game playing and Internet addiction have also been considered for inclusion in the forthcoming DSM V. This article reviews the evidence for similarities between Internet addiction and substance use disorders, their distinction from obsessive compulsive disorder, and
identifies areas of uncertainty warranting future research. There
are three different models proposed for Internet addiction (4).
Some researchers have considered the impulse-control disorders as part of the obsessive-compulsive disorder spectrum a
model. This model is supported by brain-imaging and pharmacological treatment studies with Selective Serotonin Reuptake Inhibitors (SSRIs) (although other treatments and brainimaging studies may challenge it). Secondly, the DSM V task
force has decided to create a separate category of compulsive
Internet usage disorder from the nonspecified impulse-control
disorder (ICD-NOS). Thirdly, some psychiatrists have argued
that Internet addiction should be included in the behavioral


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addiction spectrum, since it shows the features of excessive
use despite adverse consequences, withdrawal phenomena, and
tolerance that characterize many substance use disorders; however, there are little data bearing on these claims. It is not clear
whether Internet addiction usually represents a manifestation
of an underlying disorder, or is truly a discrete disease entity.
The frequent appearance of Internet addiction in the context
of numerous comorbid conditions raises complex questions of
causality. It has been argued (5) that, based on the limited available data regarding course, prognosis, temporal stability, and
response to treatment, it appears premature to consider Internet
addiction as a discrete disease entity. However, growing research
suggests that some individuals with Internet addiction are at significant risk and merit professional care and treatment. Carefully
controlled studies are required to settle these controversies. This
review searched articles published between 2000 and 2009 in
Medline and PubMed, using the key word “Internet addiction”
over the topics of diagnosis, phenomenology, epidemiology, and

The diagnosis of Internet addiction (dependence) remains
problematic. It does not appear in any official diagnostic system,
including DSM-IV, and there are no widely accepted diagnostic
criteria. Four components have been suggested as essential to
the diagnosis (6): 1) excessive Internet use, often associated with
a loss of sense of time or a neglect of basic drives, 2) withdrawal,
including feelings of anger, tension, and/or depression when the
computer is inaccessible, 3) tolerance, including the need for
better computer equipment, more software, or more hours of use,
and 4) adverse consequences, including arguments, lying, poor
school or vocational achievement, social isolation, and fatigue.
There are currently no diagnostic instruments for Internet addiction that show adequate reliability and validity across countries. A recent systematic analysis of the various diagnostic
instruments found that previous studies utilized inconsistent
criteria to define Internet addicts, applied recruiting methods
that may cause serious sampling bias, and examined data using primarily exploratory rather than confirmatory data analysis
techniques to investigate the degree of association rather than
causal relationships among variables (7). Thus, prevalence data
on pathological Internet use are limited by methodological difficulties concerning the diagnosis and the heterogeneity of diagnostic instruments. This makes it difficult to compare prevalence
rates across countries.
The questionnaires for diagnosis of Internet addiction have
used items from substance dependence questionnaires, as well
as new items related to Internet addiction. The most commonly
used questionnaire is Young’s Internet Addiction Scale (IAT)
(cut off point score 70 and above), which has been validated
in the United Kingdom (8), the United States (9), Finland (10),
and Korea (11). The Chen Internet Addiction Scale (CIAS) has
been widely used in Taiwan (12, 13). The Questionnaire of Ex-

periences Related to Internet has been validated in Spain (14),
the Compulsive Internet Use Scale (CIUS) in Holland (15), and
the Problematic Internet Use Questionnaire (PIUQ) in Hungary
(16). The assessment methods have been reviewed by Beard
(17). The IAT was developed to help Internet addicts, those who
are not sure if they are Internet addicted, and those who believe that they know someone who is pathologically using the
Internet. The PIUS has the advantage of having 7 subscales of
Internet addiction that were correlated with psychosocial health
variables including: depression, loneliness, shyness, and selfesteem. These instruments are based on different theoretical underpinnings and do not agree on the underlying dimensions that
make up problematic Internet use. Another criticism is that some
items do not relate to addiction. There are also general concerns
related to using self-reports, having dishonest answers, participants may not understand various questions or misinterpret the
various test items. Additionally, there is also a problem of selection bias with the participant pool obtained from Web sites or
undergraduate courses and no adequate control group. The use
of a Web page may influence how people responded as well as
the number of valid responses obtained. Finally, a person may
show addictive behaviors toward one application, but not others.
International prevalence rates for Internet addiction using
questionnaires such as the IAT range from 1.5% to 8.2% (18).
In the United States, an online survey of 17,251 responders to
a joint project with ABC-NEWS.com found that 6% of those
surveyed met the criteria for Internet addiction (19). A recent
random telephone survey of the general U.S. population reported
an estimate of .3–.7% (1). A study of Southern U.S. university
students found that about a quarter met criteria for Internet
dependence (20).
In Germany, an estimated 1.5 million people, i.e., 3% of the
German population is believed to be at risk of Internet addiction
(21). The rate of problematic Internet use in Italian adolescents
was 5.4% (22). The prevalence of borderline Internet use in
Greek adolescents was 12.8%, while 10.4% of male excessive
Internet users reported addictive Internet use (23). Using the
Pathological Internet Use (PIU) scale in British students, 18.3%
were considered to be pathological Internet users (24).
Internet addiction has been most studied in the Far East. A
Chinese study using the IAT scale found that, among responders
aged 13 to 18 years, 10.2% used the Internet moderately and
.6% was severely addicted (25). Prevalence rates of Internet
addiction range from 6.44% in Shaanxi Province in China (26)
to between 2.4% and 5.52% in Hunan province in China (27, 28).
Among Taiwanese university freshmen, 17.9% were addicted to
the Internet (29). Among Korean middle school students, 16%
were potential at-risk users and 3.1% were high-risk users (30).
Other studies in Korea have found 4.3% (31), 10.7% (32), 20.3%
(33), 1.6% (34), and 3.5% (35) of adolescents diagnosed with
Internet addiction. The main difficulty with these studies is that
they use vague terms to describe levels of Internet use, such as
“borderline,” “excessive,” “at risk,” and “addictive,” which are
not operationally defined or clinically validated. The prevalence


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rates of Internet addiction have been examined elsewhere (12,
Cross-sectional studies on samples of patients report high
comorbidity of Internet addiction with psychiatric disorders,
such as affective disorders, anxiety disorders (including generalized anxiety disorder, social anxiety disorder), and attention
deficit hyperactivity disorder (ADHD). It has been suggested
(37) that the relationship between loneliness and preference for
online social interaction is spurious and that social anxiety is
the confounding variable.
German Internet-dependent students had a 78% rate of comorbid depressive mood disorder and higher rates of impulsivity and depression (38). A higher percentage of anxiety disorder
was found in a group of problematic Internet users compared
with nonproblematic users of the Internet (39). Comorbidity
with hypomania, dysthymia, obsessive compulsive personality
disorder, borderline personality disorder, and avoidant personality disorder was found in U.S. adolescents (9). A combination of
alexithymia, dissociative experiences, low self-esteem, and impulse dysregulation were suggested as-risk factors for Internet
addiction in a sample of Italian adolescents (40). Male students
in Finland had higher mean score on the IAT than women and
subjects with cannabis use had higher mean score on the IAT
compared to non-users (10). There was a significant association
between Internet addiction and depressive symptoms in South
Korean adolescents (33), along with high levels of depression
and suicidal ideation (34).
Adolescents with Internet addiction had higher ADHD symptoms, depression, social phobia, and hostility in Taiwan (41).
Higher ADHD symptoms, depression, and hostility are associated with Internet addiction in male adolescents, and only
higher ADHD symptoms and depression are associated with
Internet addiction in female students. Internet addiction and impulsivity were associated with adult ADHD, and the association
between attention deficit and Internet addiction was more significant among female Taiwanese college students (42). Finally, an
association was found between Internet addiction and harmful
use of alcohol among Taiwanese students (43, 44). It is unknown
whether Internet addiction and these comorbid disorders could
be explained by shared risk factors or are best considered as
secondary disorders.
Currently, there have been very few studies on the neurobiology of Internet addiction. There were reported studies on
computer and videogame addiction (see Weinstein, elsewhere
in this issue). Among the first brain imaging studies (13) has
reported 10 participants with online gaming addiction who
were presented with gaming pictures and the paired mosaic
pictures while undergoing functional magnetic resonance imaging (fMRI) scanning. In the addicted group, right orbito-frontal


cortex, right nucleus accumbens, bilateral anterior cingulate and
medial frontal cortex, right dorsolateral prefrontal cortex, and
right caudate nucleus were activated in contrast to the control
group. The activation of the regions-of-interest (ROI) was positively correlated with self-reported gaming urge and recalling
of gaming experience provoked by the pictures. The results
demonstrated that the neural substrates of cue-induced gaming
urge/craving in online gaming addiction was similar to that of
the cue-induced craving in substance dependence. Thus, the results suggested that the gaming urge/craving in online gaming
addiction and craving in substance dependence might share the
same neurobiological mechanism.
There is some evidence for genetic factors influencing Internet addiction. A Korean study (45) compared adolescents diagnosed with excessive Internet use with healthy control subjects
on genetic polymorphisms of the serotonin transporter gene
and with respect to novelty seeking and harm avoidance on
Cloninger’s Tridimensional Personality Questionnaire (TPQ).
They found that the excessive Internet users had higher frequencies of the long-arm allele (SS-5HTTLPR), greater harm
avoidance, and higher Beck Depression Inventory scores. SS5HTTLPR frequency was closely related to harm avoidance in
excessive Internet users. This study suggested that subjects with
excessive Internet use may have genetic and personality traits
similar to depressed patients.
For addicted Internet users, their excessive behavior may
serve as an (inadequate) stress coping strategy. A study of
Internet-dependent children in Germany revealed patterns of
watching television, communication, ability to concentrate in
school lectures, and preferred strategies for coping with negative emotions that differed from other children (46).
The Internet may also be used as a forum for expanding
social networks and, consequently, enhancing the chance of
meaningful relationships, self-confidence, social abilities, and
social support. Although those who primarily used the Internet
for online chat believed that the Internet is psychologically beneficial to them, they also believed that frequent Internet users
are lonely and that the Internet can be addictive. It is, therefore,
argued that “chat” users who are socially fearful may be using
the Internet as a form of low-risk social approach and an opportunity to rehearse social behavior and communication skills,
which may help them improve interactions in face-to-face social
environments (47).
Others have suggested that people with Internet dependence
use the Internet as a coping mechanism against underlying psychological developmental issues; the fifth and sixth Eriksonian
crises (identity, intimacy) were related to Internet dependence
among Taiwanese college students (48). Students who were

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Internet-dependent scored significantly lower on most measures
that reflected successful resolution of these crises, and scored
higher on the measures that reflected unsuccessful resolution of
these crises (48).
Compulsive cybersex has become a significant component
of Internet addiction for many men and women who have fallen
prey to the accessibility, affordability, and anonymity of online
sexual behaviors (49). Some patients develop problems with
compulsive cybersex due to predisposition or accidental conditioning experiences, while other compulsive users have underlying trauma, depression, or addiction. Both men and women with
cybersex problems exhibit maladaptive coping, conditioned behavior, dissociative reenactment of life trauma, courtship disorder, intimacy dysfunction, and addictive behavior (49). The
problematic Internet use group showed higher scores in the SelfDirectedness and Cooperativeness profiles and lower scores in
the Novelty Seeking and Self-Transcendence profiles of the
JTCI, compared with the nonproblematic Internet use group,
after controlling for the ADHD symptoms.
These maladaptive coping mechanisms seem overlap with
sexual addiction (see Thibaut elsewhere in this issue), but they
are using the specific media of the Internet.
In the case of compulsive cybersex, the content of display, more specifically pornography, is a specific form of sexual computer-assisted behavioral addiction. Therapists report a
growing number of patients addicted to this activity, a form of
both Internet addiction and sexual addiction, with the standard
problems associated with addictive behavior.
Several studies have examined the role of personality factors
in excessive Internet use. Higher frequency of Internet use, lack
of perseverance (an aspect of impulsivity), and online group
membership significantly predicted problematic Internet use in
Australian students (50). The personality dimension of psychoticism correlated positively with the constructs of harmonious and
obsessive passion, and this was mediated by the tendency to express one’s true self on the Internet in Turkish adolescents (51).
South Korean Internet-addicted adolescents had more interpersonal problems than healthy users (30). Personality factors such
as high harm-avoidance (HA), novelty seeking (NS), reward
dependence (RD), low self-directedness, and low cooperativeness were positively correlated with Internet addiction in two
South Korean studies (33, 52). However, there was contradictory evidence of high Self-Directedness and Cooperativeness
profiles together with low scores on the Novelty Seeking and
Self-Transcendence scales in another South Korean study (53).
Internet addiction was positively associated with social anxiety
and discontent with peer interactions (54), and with parenting
attitudes, family communication, family cohesion, and family
violence exposure (32).
In mainland China, potential risk factors for Internet addiction in adolescents were identified as being male, drink-

ing behavior, family dissatisfaction, and experience of recent
stressful events (25). Similar associations with adolescent Internet addiction were found in Taiwan, e.g., greater substance
use experience, including friends or siblings with habitual alcohol drinking, low connectedness to school, high family conflict,
low family function, perceived positive parental attitude towards
adolescent substance use, and living in rural areas (12, 41). High
NS, high HA, and low RD predicted a higher proportion of adolescents with Internet addiction, whereas high NS, low HA,
and low RD predicted a higher proportion of adolescents with
substance use (48).
Internet-addicted individuals may have difficulty suppressing their excessive online behaviors in real life. A study using
the Iowa Gambling Task found that Internet-addicted individuals have deficits in decision-making function, chiefly a strategy
learning lag rather than an inability to learn from task contingencies. They showed better performance on a Go/no-go task,
suggesting some dissociation between mechanisms of decisionmaking and those of prepotent response inhibition (55).
A recent study has investigated the neurocognitive correlates
of Internet addiction describing the characteristics of decision
making (Iowa Gambling Task), potential to take risks (BART),
and personality of college students with Internet addiction (56).
The study has shown that the addicted students on the gambling task indicated better decision making, and performance
on the BART indicated that they were not more likely to engage
in risk-taking behaviors; and (d) TPQ scores showed lower reward dependence (RD) and higher novelty seeking (NS) for the
addicts. Their higher performance on the Iowa gambling test
differentiates the Internet addiction group from the substance
use and pathologic gambling groups that have been shown to be
deficient in decision making on the Iowa test.
Very little is known about factors associated with the
outcome of Internet addiction. A prospective, population-based
study evaluating the incidence and remission rates for Internet
addiction and the associated predictive factors in Taiwanese
adolescents found that the 1-year remission rate for Internet
addiction was 49.5% (57). High exploratory excitability, low
reward dependence, low self-esteem, low family function, and
online game playing were associated with greater severity of
the Internet addiction, while low hostility and low interpersonal
sensitivity were associated with remission. A further two-year
prospective study examined the predictive values of psychopathology for the occurrence of Internet addiction (58).
Depression, ADHD, social phobia, and hostility were found
to predict the occurrence of Internet addiction in the 2-year
follow-up, and hostility and ADHD were the most significant
predictors of Internet addiction in male and female adolescents,


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respectively. Finally, a study examined the associations between
aggressive behaviors and Internet addiction and online activities
in adolescents (59). The results demonstrated that after controlling for the effects of shared associated factors and watching
violent TV programs, adolescents with Internet addiction were
more likely to have aggressive behaviors during the previous
year. The association was more significant among adolescents
in junior high schools than in senior high/vocational schools.
Online chatting, adult sex Web viewing, online gaming, online
gambling, and Bulletin Board System were all associated with
aggressive behaviors.
The known health hazards associated with Internet addiction appear related to sleep deprivation or disturbance. A South
Korean study of high school students with Internet addiction
found a 37.7% prevalence of excessive day time sleepiness,
whereas the prevalence in possible Internet addicts and nonaddicts was 13.9% and 7.4%, respectively. The prevalence of
insomnia, witnessed snoring, apnea, teeth grinding, and nightmares was also higher in Internet addicts compared with possible
addicts and non-addicts (60).
Prior research explores the addictive qualities sustaining drug
and alcohol abuse, pathological gambling, and even video game
addiction; however, given the relative newness of Internet addiction, little is understood about the habit-forming nature of the
Internet and its potential for abuse. As the Internet permeates our
lives at home, school, and work, the Internet can create marital-,
academic-, and job-related problems (61–63). A study of a small
sample of adult Italian Internet addicts showed that the disease
was felt to be strongly disabling, especially for family life (9).
A close look to the subjective experience during the Internet
use would be helpful for distinguishing between pathological
cases from just problematic. The Italian study has shown that
dissociative symptoms were prominent and strongly related
with measures of IAD severity, subjective disability, and OCD
Treatment for Internet addiction is based on interventions
and strategies used in the treatment of substance use disorders.
Psychosocial approaches are the mainstay of treatment, with
very little study of pharmacological treatment. Due to the lack of
methodologically adequate research, it is currently impossible to
recommend any evidence-based treatment of Internet addiction
There is preliminary evidence for success of an “initiated abstinence” program in 12–15 year old pupils in Austria, Germany,
and Italy (64), and for a counseling program in Hong Kong (65).


Preliminary results from a study of 114 patients receiving cognitive behavior therapy indicated that most clients were able
to manage their presenting complaints by the eighth session,
and symptom management was sustained at 6-month follow-up
(66). There are no evidence-based treatments for Internet addiction. Cognitive behavioral approaches and psychosocial support
may be helpful. Marital and family therapy may help in selected
cases, and online self-help books and tapes are available. Lastly,
a self-imposed ban on computer use and Internet access may be
necessary in some cases (67).
There are media reports that unlicensed training camps in
China are used to “wean” children, often in their teens, from
overuse of the Internet, which has resulted in the death of at least
one youth (68). In November 2009, the Chinese government
banned physical punishment to “wean” teens from the Internet
(69). A residential treatment center for pathological Internet use
(ReSTART) has recently been established in Seattle, WA, but
no outcome results are yet available.
Given that there is comorbidity between Internet addiction
and other psychiatric disorders such as OCD and ADHD, several studies have used pharmacological agents that are designed to address the common mechanism. Others have identified the comorbidity with ADHD as the rationale for using
methylphenidate in children with Internet video game addiction
together with ADHD (11). A pharmacological open-label treatment study using extended release methylphenidate (mean dose
30.5 +/− 13.3 mg/d, range 18–54 mg/d), in 62 Korean children with Internet video game addiction and comorbid ADHD
found that, after 8 weeks of treatment, measures of Internet
use and Internet use duration were significantly reduced, and
this improvement was positively correlated with improvement
in measures of attention. These findings led the investigators to
suggest that Internet video game playing might be a form of
self-medication for children with ADHD.
Another study has identified the comorbidity of impulsivecompulsive Internet use with OCD to examine whether SSRIs
such as Escitalopram can be useful for treatment of Internet addiction (71). A pharmacological open-label treatment study using Escitalopram (dose 10 mg/day) with impulsive-compulsive
Internet users showed significant decrease in the number of
hours spent on the Internet during the first phase of treatment
(week 1–10) but not later. Further placebo-controlled doubleblind studies are required.

Internet addiction, i.e., excessive use of the Internet with
resulting adverse consequences, does not appear in any official
diagnostic system, including DSM-IV. Block has argued
that Internet addiction is a common disorder that merits
inclusion in DSM-V (5). Conceptually, the diagnosis is a
compulsive-impulsive spectrum disorder that involves online
and/or offline computer usage. At least three subtypes have
been identified: excessive gaming, sexual preoccupations, and

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e-mail/text messaging. All of the variants share the following
four components: 1) excessive use, often associated with a loss
of sense of time or a neglect of basic drives, 2) withdrawal,
including feelings of anger, tension, and/or depression when the
computer is inaccessible, 3) tolerance, including the need for
better computer equipment, more software, or more hours of
use, and 4) adverse consequences, including arguments, lying,
poor achievement, social isolation, and fatigue. Others have
argued that Internet addiction is not a true addiction and may
be no more than a symptom of other, existing disorders such
as anxiety, depression, ADHD or impulse control disorders
(70). Little data are available to resolve this question, and the
pathophysiological mechanisms underlying Internet addiction
remain unknown. This relative ignorance also extends to
treatment. The few published treatment studies for Internet
addiction are based on interventions and strategies used in the
treatment of substance use disorders. Thus, it is impossible to
recommend any evidence-based treatment of Internet addiction.
A systematic literature review was conducted by means of
PubMed using “Internet addiction” for electronic search, up to
November 2009.
Declaration of Interest
Dr. Weinstein is now supported by the Israeli Anti-Drug
Authority and the National Institute for Psychobiology in Israel.
The authors report no conflicts of interest. The authors alone are
responsible for the content and writing of the article.
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